Orthopaedics in crisis and conflict situations: Evidence not heroism

"The rise in armed conflicts - also in Europe - makes the need for adequate training obvious. Only then can medical personnel deal with the types of specific patterns of disease and injury occurring in gunshot wounds or explosions. Academic surgery has not yet delved deeply enough into the specific characteristics of traumatology and orthopaedics in conflict situations," trauma surgeon Dr Bernhard Ciritsis from Zurich told the 15th EFORT Congress in London.

A special session was devoted precisely to the specific challenges in war and crisis situations. "The EFORT Congress is the only hub of this dimension outside the Anglo-American world for promoting communication between the field of academic surgery and on-site surgery in conflict situations. The aim of the session is to generate evidence-based conclusions and to have both sides develop further from this exchange among experts," Dr Ciritsis explained.

"This subject field is not restricted to war situations. It covers all types of conflict scenarios and natural disasters such as tsunamis, floods, earthquakes, stampedes or explosion injuries. In an effective collaboration with the International Committee of the Red Cross (ICRC), Médecins Sans Frontières (MSF) and military units, a scientific network was able to be built up for the purpose of sustainably sharing facts that are communicable and objectively verifiable. With eye witness reports, there is the danger of resorting to clichés, especially stereotypes about developing countries. This factual approach makes the EFORT Congress an important authority and lends it an exclusive character," according to Dr Ciritsis.

Congress participants discussed issues ranging from quality standards in surgery under precarious conditions to the consequences of the long-term presence of humanitarian organisations in developing countries; from treatment strategies in natural disasters and the management of mass casualty incidents to the analysis of gunshot wounds using an ICRC-generated algorithm.

Need for specific algorithms

Ballistic traumata or gunshot wounds exhibit biomechanics and kinetics not found in traffic accidents. Medical personnel are therefore confronted with a different set of symptoms. Dr Ciritsis: "The only classification thus far is from ICRC with a specific database, which no university hospital has. The classification of ballistic traumata is indispensable for creating an algorithm in emergency medicine." Without an algorithm, life-saving actions might not be taken with the necessary speed.

The need for evidence-based conclusions and specific algorithms is also evident in connection with mine injuries or earthquake victims who have their characteristic bruises, recumbent traumata and open fractures. The earthquake disaster in Haiti bore extreme witness to this need. Dr Ciritsis: "Carrying out amputations on extremities involves more than just cutting off limbs. It requires solid scientifically based knowledge with respect to adequate prosthetics and efforts to retain motor functions to the greatest possible extent."

Growing threat for medical personnel

One important fact is the problem of providing medical care in conflict situations. In regions affected by crisis and warfare such as Somalia or Syria, many people have no access to medical care because of the threatening situation. "Wars have become more urban and more subtle. There is an increase in attacks on the vulnerable and thus also in the threat to medical personnel. A central aspect of surgery in conflict situations is therefore to improve the safety of the affected population and medical care teams," Dr Ciritsis emphasised.

Rejection of neo-colonialist mindsets

"Surgery in conflict situations has nothing to do with the idea of 'anything goes'. It is essential to comply with universal premises of medical ethics, just as it is to reject categorically any patterns of neo-colonialist thought and behaviour or any arrangements smacking of two-class medicine. Although 'keep it simple' is the principle that often prevails in these precarious working conditions, the same medical standards must be applied as in a hospital in a Western industrial nation," Dr Ciritsis noted. "Medicine in crisis and conflict situations has no place for alleged heroism or self-styled one-man shows. Medical procedures in these extreme situations only work if everyone on the team exercises maximum discipline and cooperates on an equal footing, from the medical and nursing staff to the logistics personnel including local employees. A fundamental attitude of respect is required, as is professionalism, which covers a broad spectrum of qualifications, from general and trauma surgery and orthopaedics to paediatric, micro and reconstructive surgery."

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